Radial forearm flap in maxillo-facial surgery

Thirty consecutive patients treated with a free radial forearm flap are reviewed. The flap was used in the reconstruction of intraoral defect in 24 patients and of extraoral defect in 6 patients. There were no total or partial flap failures. Donor site complication included a partial loss of skin graft in 4 and radial fracture occurred in 1 patient. The authors considered the application of the radial forearm flap a reliable method for resurfacing large skin defects of the face. However, according to their conviction the most important field of the forearm flap is its use in intraoral reconstruction after pull-through operation. Attention is drawn to the limitation of the use of osteocutaneous flap in the replacement of segmental mandibular defect.     

Reverse dorsal metacarpal osteocutaneous flap

There are a number of possibilities for local and vascularized bone transfer when a small amount of cortico-cancellous bone is required in the hand and fingers. The authors describe the dissection technique and a clinical application of a reverse dorsal metacarpal osteocutaneous flap to reconstruct the proximal phalanx of a fifth finger. They emphasise the bone vascularisation, studied 48 hours postoperatively with a bone scan and confirmed with bone healing 4 weeks later. The advantages are: it is a compound flap, easy to dissect under tourniquet in one operation, it can be done in an emergency care situation and it does not require ligation of an important vascular axis. The essential precaution is to visualise the patency of the fourth dorsal metacarpal artery before flap dissection, acknowledging that in only 63% of cases is there a vascular pattern that allows flap dissection with a long arc of rotation.     

Pharyngoesophageal reconstruction using the tubed free radial forearm flap

Patients undergoing laryngopharyngectomy require the restoration of both deglutition and voice. We believe the tubed radial free flap offers the combined advantages of a rapid harvest with minimal morbidity, a long flap pedicle, extraordinary reliability, and the possibility of customization to fit virtually any size of defect. This flap does have a somewhat higher leakage rate; however, such leaks are relatively minor and nearly all will resolve with a brief period of conservative treatment. Postoperatively, this flap tolerates radiation therapy very well. Most importantly, it maximizes the functional rehabilitation of the patient by providing the best speech and swallowing results available. For these reasons we consider the tubed radial forearm free flap to be the flap of choice for circumferential pharyngoesophageal reconstruction.     

Microsurgical reconstruction of facial defects using a forearm flap

The perforating facial defects are often results of the removal of malignant tumours and less commonly are caused by accidents and shotgun injuries. The advent of musculocutan flaps and the microvascular tissue transplantation has made essential changes in the treatment of full thickness cheek defects during the last decade. The authors describe three cases, where the reconstruction has been made with free radial forearm flaps.     

The distally based forearm island flap in hand reconstruction

The distally based forearm island flap is vascularized by the perforators of the distal radial artery. The skin flap is along the axis of the radial artery, and the pivot point of its subcutaneous pedicle is about 2 to 4 cm above the radial styloid process. We have treated 12 patients with 12 flaps for soft-tissue defects of the hand. Of these recipient sites, seven were in dorsal hands, two were in thumbs, two were in forearms, and one was in the palmar area. The donor-tissue variants included eight skin flaps, two adipofascial flaps, and two sensate flaps. The sizes of the flaps ranged from 6 x 4 cm to 14 x 6 cm. The donor site wound could be closed primarily in five patients. Two sensate flaps, innervated by the lateral antebrachial cutaneous nerve, could provide sensation for thumb reconstruction. The advantage of this flap is its constant and reliable blood supply without sacrifice of the main radial artery. The elevation of the flap is simple and rapid. There is the potential that this flap can be used as an innervated flap, and there is no need of microsurgical technique.     

Posterior interosseous reverse forearm flap: experience with 80 consecutive cases

The results of an anatomic investigation performed in 40 fresh cadaver specimens and 80 consecutive clinical cases of the posterior interosseous reverse forearm flap are reported. It was observed that there is a choke anastomosis between the recurrent dorsal branch of the anterior interosseous artery and the posterior interosseous artery at the level of the middle third of the posterior forearm. Ink injections through a catheter placed in the distal part of the anterior interosseous artery stained the distal and middle thirds of the posterior forearm, but the proximal third remained unstained; this secondary territory cannot be captured through the choke anastomosis between the anterior interosseous artery and the posterior interosseous artery. Intravital fluorescein injection into the distal arterior interosseous artery revealed (under ultraviolet light) that the distal third of the posterior forearm is irrigated by direct flow through the recurrent branch of the arterior interosseous artery (the traditionally called distal anastomosis of the interosseous arteries). Therefore, we can assume that the blood flow is not reversed when the so-called posterior interosseous reverse forearm flap is raised. From this point of view, this flap could be renamed as the recurrent dorsal anterior interosseous direct flap; however, the classical name is maintained for practical purposes. From the venous standpoint, the cutaneous area included in this flap belongs to an oscillating type of venous territory and is connected to the deep system through an interconnecting venous perforator that accompanies a medial cutaneous arterial branch located at 1 to 2 cm distal to the middle point of the forearm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Role of the perforating vein in vascular pedicle of free forearm flap

An innovation in the preparation of the vascular pedicle of the free radial forearm flap is presented. While the radial artery is commonly used as the arterial pedicle of the flap, either the cutaneous venous system or the radial comitant vein (deep venous system) is used as the venous pedicle. The perforating vein communicates between these two venous systems at the cubital fossa, and we confirmed its presence in all but one of more than 180 cases. When the vascular pedicle is dissected proximally to the perforating vein contained in the flap, the venous drainage of both the deep and cutaneous systems can be restored by anastomosis of only one vein: the cutaneous or the radial comitant vein. On the other hand, the flap can be raised with the radial vessels (without the cutaneous vein) at the start of surgery, and a large caliber cutaneous vein, such as the median cubital, the cephalic, or the basilic, can be used for anastomosis in cases where the cutaneous veins in the distal forearm are too thin, or where the radial comitant vein is composed of two thin separated veins. We believe that preserving the perforating vein would make the forearm flap more reliable and more convenient in reconstructive surgery.     

Limiting donor site morbidity by suprafascial dissection of the radial forearm flap

A technique of suprafascial flap elevation to prevent donor site problems is described, based on careful intraoperative observation of the anatomical relations of all involved structures in a series of over 400 free forearm flaps used in various reconstructive procedures.     

Oromandibular reconstruction using a keel-shaped modification of the radial forearm osteocutaneous flap

The keel-shaped modification for harvest of the radial forearm osteocutaneous flap has been used to reconstruct 19 oromandibular defects in 18 patients. Fourteen men and 4 women ranging in age from 22 to 72 years have undergone composite mandibular reconstruction, with follow-up ranging from 3 to 36 months. Sixteen patients (17 reconstructions) had resection of advanced malignancies, and 2 patients sustained shotgun wounds. Twelve symphyseal and 7 lateral or posterior defects were reconstructed with donor radius bone ranging in length from 5 to 13.5 cm. Double osteotomies were performed in 7 patients. Two skin paddles were used in 4 patients to provide simultaneous intraoral lining and external skin coverage. The radial forearm osteocutaneous flap is still an excellent choice for oromandibular reconstruction. Anterior and lateral composite mandibular defects were satisfactorily reconstructed both aesthetically and functionally using the keel-shaped modification of the radial forearm flap. Donor-site problems were uncommon and minor, and long-term forearm function was minimally affected. Radius fracture occurred in only 1 patient.     

A new flap from the dorsum of the first intermetacarpal area: the first dorsal intermetacarpal flap

Soft-tissue reconstruction of the hand still remains a challenge for plastic and reconstructive surgeons. Several flaps have been described to cover soft-tissue defects of the digits and the hand. In the first web region, there are some communications between the intermediate artery arising from the dorsal branch of the radial artery and the volar arteries of the thumb and the index finger. Depending on these communications, a new distally based flap is raised from the first dorsal intermetacarpal area. This flap has been used to cover various defects of the thumb in four patients and the distal radial side of the palmar area in one patient. Donor sites have been closed primarily except in one patient. There were no complications, and the results show that this flap is useful to cover soft-tissue defects of the thumb and proximal phalanx of the index finger as well as the radial side of the palmar and dorsal surfaces of the hand.     

The second dorsal metacarpal flap with vascular pedicle composed of the second dorsal metacarpal artery and the dorsal carpal branch of radial artery

A pedicle second dorsal metacarpal flap, comprising the second dorsal metacarpal artery, the partial carpal arterial arch of the dorsal hand, and the dorsal carpal branch of radial artery, was designed. The flap may be rotated through two axes of rotation, one at the entry of carpal branch of radial artery into the first dorsal interosseous muscle and one at the entry of the recurrent cutaneous branch arising from the second dorsal metacarpal artery into the skin. The method introduced can increase as much as possible the length of the vascular pedicle of the second dorsal metacarpal flap. Thus, it can cover a small defect at a more distant area. If the width of this flap is not more than 3 cm, the donor site can be closed directly. The flap had been used in five cases with no necrosis of the flap or complication of the donor site. In further investigation of the postoperative patients, no stiffness and tightness have been observed through a short period of rehabilitation of the hand. The results are satisfactory. The anatomy, the operative technique, and three selective cases are described here.     

The fabricated radial forearm flap in pharyngolaryngeal surgery: saliva leakage and its prevention

Reconstruction of the circular pharyngo-oesophageal defect continues to represent a formidable challenge for the head and neck surgeon. The fabricated radial forearm flap can provide thin and pliable skin and has potential in this one-stage reconstructive surgery. However, major problems with this technique are saliva leakage, fistula formation and stricture of the oesophageal anastomosis. Our experience with this flap for 11 pharyngo-oesophageal reconstructions has given us a better understanding of how to prevent these complications. Fistula formation and stricture were problems in our first two cases. With the 9 following cases, prevention of these complications was achieved by positioning the T-shaped suture lines of the tubed flap posteriorly. Our results suggest that adequate protection of the T-shaped suture lines during fabrication and anastomosis of the forearm flap is important in the prevention of saliva leakage.     

Results after resection of intraoral cancer and reconstruction with the free radial forearm flap

OBJECTIVE: Prospectively evaluate the effect on the nutritional status of a glucose polymer as energy supplementation alone in chronic hemodialysis patients with moderate and severe malnutrition. MATERIAL AND METHODS: The nutritional status of 55 hemodialysis patients was assessed by using a score that included Iron binding capacity, albumin, cholesterol, body mass index, mid brachial circumference, arm muscle area, triceps skinfold, and clinical impression. Twenty-two of 27 patients (14 men and 8 women, mean age 43 +/- 15 years, time on dialysis 65 +/- 49 months) were classified as moderately or severely malnourished and were supplemented for 6 months with 100 g of glucose polymers per day (equivalent to 380 kcal or 1590 kJ) added to the usual food intake. The patients were reevaluated at 3 and 6 months. RESULTS: Only body weight, body mass index, triceps skinfold, and brachial circumference and clinical impression increased significantly at the end of the third month (P < .05) in the 22 patients. These results were confirmed at 6 months in 18 patients that completed the study. Mean body weight increase was 2.4 kg (range, .2 to 6.3 kg). The nutritional status, evaluated through the score, improved in only 4 patients at the end of the study. Few gastrointestinal side effects were observed. Triglycerides increased from 136 +/- 40 mg/dL to 235 +/- 120 mg/dL. Follow-up of the patients showed that fat mass (assessed by anthropometry) was maintained for 6 months after supplementation was discontinued. CONCLUSION: Energy supplementation alone in patients with moderate and severe malnutrition on chronic hemodialysis resulted in an increase in body weight, owing to an increase in body fat, but the nutritional status did not improve.     

Resurfacing of the donor defect after wrap-around toe transfer with a free lateral forearm flap

BACKGROUND: One-week proton pump inhibitor-based triple therapies are very popular in the US despite limited US data documenting efficacy. We assessed 1-week proton pump inhibitor triple therapies for Helicobacter pylori, and compared them to dual antibiotic therapies (to assess benefit of omeprazole) and to omeprazole-amoxycillin (to assess benefit of clarithromycin) in a large, randomized, US multicentre study. METHODS: Healthy subjects who were H. pylori-positive by rapid serological test and 13C-urea breath test were randomly assigned to (i) omeprazole (O) 20 mg b.d. + amoxycillin (A) 1 g t.d.s. for 14 days (OA); (ii) A 1 g b.d. + clarithromycin (C) 500 mg b.d. for 7 days (AC); (iii) C 250 mg b.d. + metronidazole (M) 500 mg b.d. for 7 days (CM); (iv) O 20 mg b.d. + C 250 mg b.d. + M 500 mg b.d. for 7 days (MOC); or (v) O 20 mg b.d. + C 500 mg b.d. + A 1 g b.d. for 7 days (OAC). Repeat breath tests were done at 6 weeks to assess H. pylori status. RESULTS: Three hundred and two H. pylori-positive subjects at 25 centres received medication. Intention-to-treat cure rate was significantly higher for OAC (82%) than for MOC (67%), CM (59%), AC (18%) or OA (58%), Per-protocol cure rates were 85% for OAC and 75% for MOC. Discontinuation of therapy due to a side-effect occurred in 0-3% of each study group. CONCLUSIONS: One-week twice-daily triple therapy with omeprazole, amoxycillin and clarithromycin provides the best rate of eradication of the five regimens studied. However, treatment in the US for 7 days may be unable to achieve eradication rates of > or = 90% with proton pump inhibitor-based triple therapy.